Family History Form - Pediatric Healthcare Associates

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FAMILY HISTORY FORM
DATE _____________
PEDIATRIC HEALTHCARE ASSOCIATES
Patient’s Name ___________________________ Nickname ______________ Date of Birth __________
Other children with same parents: ______________________________________________________
Date of Birth
Height
Illness/Medical Problems
Father of child
Mother of child
Illness/Medical Problem
Age Died
Cause
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Does anyone in your family have any of the following diseases? If so, state the relationship to the child.
Yes
No
Relationship
Yes
No Relationship
ADHD
Hearing Loss
Alcoholism/Drug Use
Heart Disease
Allergies
Hemochromatosis
Asthma
High Cholesterol
Autism
Hypertension
(high
blood pressure)
Birth Defects/Genetic
Immune Disorders
Problems
Bleeding Problems
Infertility/PCOS
Blood Clots
Lazy Eye
Cancer & type
Mental Illness
(depression, bipolar, anxiety)
Congenital Cataract
Migraines
Celiac Disease
Overweight/Obesity
Developmental
Renal Disorder
(kidney)
Delays/Learning
Disabilities
Diabetes, type 1 or 2
Retinoblastoma
Eating Disorders
Rheumatologic
Disorder
Eczema
School Problems
Epilepsy
Scoliosis
(seizures)
Food Allergy
Sickle
Cell/Thalassemia
Gastrointestinal
Smoking
Disease
(colitis, Crohn’s)
Glaucoma
Thyroid Disease
Are there any other medical problems that run in your family? __________________________________
_____________________________________________________________________________________
Revised 9/14

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